New Orleans—Patients in postsurgical recovery, in the midst of oncologic treatments, or in the ICU frequently rely on patient-controlled analgesia (PCA) pumps to alleviate their pain. While PCA reduces suffering and effectively controls intake of highly addictive medications, a new study identified a sobering pattern of consistent errors, missing data and an alarming underestimation of bolus amounts that have the potential for devastating adverse outcomes for patients.

“We observed a discrepancy between the PCA pump and the medical record, so we asked, ‘How frequently is this happening and why is it happening?’” said Ryan Nguyen, a fourth-year medical student, who looked into those questions with a team of doctors from the Departments of Anesthesiology and Perioperative Care as well as Palliative Care at the University of California, Irvine Medical Center (UCIMC), in Orange.

The research team took a two-pronged approach to compare actual PCA-administered doses with electronic medical record (EMR) documentation in various departments within their hospital.

First, Mr. Nguyen retrospectively analyzed PCA documentation found in the EMRs of the hospital’s patients for the first two months of 2019. Next, the team conducted a real-time analysis of 19 PCA pumps, comparing information from the pump’s computer with what appeared in the EMR.

Alongside his advisor, Shalini Shah, MD, Mr. Nguyen presented the results at the American Society of Regional Anesthesia and Pain Medicine’s 2019 annual Fall pain meeting (abstract 73). The study revealed consistent and prevalent errors in the documentation of PCA pump dosage that resonated with the audience.

“We were approached by several directors of pain management at other hospitals who thanked us for our presentation and our data, since this issue is prevalent at their institutions, too,” Mr. Nguyen said.

Their data produced some troubling results. For the retrospective analysis, 87% of the time a patient had at least one type of documentation error—either mathematically incorrect data or missing information.

The data showed that only half of four-hour totals were mathematically correct, as were only one-fourth of 24-hour totals. As for missing data, only around one-fourth of four- and 24-hour totals were documented completely at every four-hour increment.

In the real-time analysis, patients received nearly 21% more opioids than what was documented. Furthermore, the average patient had 7.5 more attempts and 4.1 more doses than what was noted in the EMR.

“That’s very concerning,” Mr. Nguyen said. “Doctors write out prescriptions based on the EMR. Without accurate documentation, the patient may head home with a prescription that compromises effective pain management. The patient won’t have optimal pain control.”

Doctors and management at UCIMC were aware of common documentation errors, but the extent of the problem was not clear until Mr. Nguyen and Dr. Shah presented their data. The study also shows an urgent need for an institutional investment in automating IV communication, including the PCA pump.

“This poster exposes several issues that need research and innovation,” said Kiran F. Rajneesh, MD, MS, the director of the Neurological Pain Division and an assistant professor in the Department of Neurology at the Ohio State University Wexner Medical Center, in Columbus. “The human error with reporting in the medical chart by a nurse/health care personnel is primarily due to lack of direct interface between the pump and electronic medical chart server.”

Dr. Rajneesh, who was not involved in the study, added, “We need to develop and incorporate interfaces that medical devices can communicate with medical charts that is safe, effective, quick but yet secure and impervious to electrical, magnetic and hacker interference. These interfaces also need to be universal at least nationally so devices that are interfaced during hospital-to-hospital transfer, air transport and EMT [emergency medical technician interactions] can continue to seamlessly work without hindering emergent patient care.”

Mr. Nguyen and Dr. Shah tout the exemplary work of the nurses at the UCIMC and insist that for nurses to adhere to institutional protocol, they need tools that share an interface with the EMR.

“The nursing staff is second to none here, but since they are human beings, errors in calculation and documentation cannot be avoided,” Mr. Nguyen said. “This is unfortunately a day-to-day problem that nurses face, a problem that can be prevented with appropriate medical technology that optimizes PCA documentation.”

In lieu of technology, the poster suggested a standardized data collection form for nurses to use when documenting bolus amounts every four hours as the hospital’s PCA protocol mandates. The hospital’s care committee meetings adopted the suggestion after analyzing the numbers in Mr. Nguyen’ study.

Although that form should aid in creating a more accurate picture, Mr. Nguyen and Dr. Shah hope to see EMR-integrated PCA pumps at UCIMC, which researchers at the hospital are looking to institutionalize.

“This is just one example of where using data to drive meaningful change in process management can cause a dramatic improvement in quality outcomes in hospitals,” Dr. Shah said.

Others see a lesson for nurses and the hospital in workload management and in improving EMR accuracy.

“With the advances in EMR technology, in a perfect world, all systems could be linked to improve documentation and prevent errors,” said Selena Gilles, DNP, a clinical assistant professor at NYU Rory Meyers College of Nursing, in New York City, who was not involved in the study. “Realistically, a nurse’s shift can be very unpredictable, with factors like acuity, staffing and available resources having an impact on their workload and documenting abilities.

“In order to reduce errors, nurses can better manage their workload by asking for help when needed and utilizing their colleagues as resources,” she added. “This can include a checks and balances system between colleagues, for example, bedside report with the incoming and outgoing nurse verifying the amount of medication left in a PCA, as well as both nurses documenting and cosigning. In addition, nurse-led quality improvement initiatives can be beneficial in developing and reinforcing unit-specific policies surrounding accurate documentation in order to prevent errors.”

Heather Jackson, PhD, RN, the administrative director of advanced practice for Vanderbilt-Ingram Cancer Center, in Nashville, Tenn., who was not involved in the study, noted that the poster showed missing data in the EMR. She echoed the call for a two-person team on every PCA pump. “Furthermore, hard stops in the medical administration record could help eliminate data omissions,” she said.

—Jordan Davidson

Video by Meaghan Lee Callaghan